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The Peminic-Greeley Patient Safety Organization

The Peminic-Greeley Patient Safety Organization

The Peminic-Greeley Patient Safety Organization provides a unique opportunity for members to improve patient safety in their organizations.

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  • FDA: Only you can prevent surgery fires

    This June, FDA issued an alert reminding healthcare professionals and facility staff of “factors that increase the risk of surgical fires on or near a patient.” The agency also recommended practices to reduce the occurrence of surgical fires, including “the safe use of medical devices and products commonly used during surgical procedures.”

    The alert is targeted at healthcare professionals involved in surgical procedures—such as surgeons, surgical technicians, anesthesiologists, anesthesiologist assistants, certified registered nurse anesthetists, physician assistants, and nurses—and staff responsible for patient safety and risk management.

    “Although surgical fires are preventable, the FDA continues to receive reports about these events,” read the alert. “Surgical fires can result in patient burns and other serious injuries, disfigurement, and death. Deaths are less common and are typically associated with fires occurring in a patient's airway.”

    This report comes 13 months after the FDA warned that certain lithium battery–powered medical carts had been overheating, igniting, smoking, burning, or exploding. In some cases, firefighters have had to bury medical carts to put out the flames.

    When fires break out
    ECRI Institute estimates that, based off the nonprofit research organization’s reporting data from Pennsylvania that has been scaled to encapsulate the entire country, there are between 90 and 100 surgical fires in the U.S. every year, down from 550–650 in 2007. ECRI Institute estimates that about 10%–15% of these surgical fires are major, leading to serious injuries or disfiguration.

    In 2016, a man in Florida was getting a cyst removed from his forehead when a surgical tool caught cloth on fire during surgery, causing third-degree burns on his face, according to a news report. Another news report out of Chicago said that in 2012, a man having a catheter implanted in his chest suffered surgical fire burns so painful that he "prayed to God to just let me die."

    In rare cases, as the FDA noted, surgical fires can be fatal. For example, a 65-year-old woman undergoing surgery at an Illinois hospital in 2009 died six days after being burned during a “flash fire” in the OR.

    It’s not just patients who can be harmed. Healthcare workers are also at danger of being injured when surgical fires occur. Plus, medical equipment and devices are at risk of damage, too.

    Fire starters
    “A surgical fire can occur when all elements of the fire triangle are present,” Scott Lucas, PhD, PE, director of ECRI Institute’s Accident and Forensic Investigation team, explained via email. Those three elements, he wrote, are a fuel, such as drapes, gauze, breathing tubes, or prepping agents; an oxidizer, such as oxygen or nitrous oxide; and an ignition source, such as a laser or electro-surgical pencil.

    “Procedures involving the face, head, neck and upper chest (above the xiphoid) are of the greatest risk, particularly in the presence of supplement oxygen,” Lucas wrote in the email.

    Lucas also noted that more than 70% of surgical fires involve oxygen enrichment, which OSHA defines as any atmosphere that contains more than 22% oxygen. He added that “alcohol-based prepping agents also pose a high risk of fire if the agent has not dried prior to beginning the procedure.” The recommended drying time for prepping agents should be listed in product instructions, Lucas wrote.

    In its alert, the FDA wrote that it “reviews product labeling for drugs and devices that are components of the fire triangle to ensure the appropriate warnings about the risk of fire are included.”

  • Mandatory glove wearing may reduce risk of hospital-acquired infections

    Infection rates are reduced when physicians are required to wear gloves, according to a study published in the journal Pediatrics. Read on to find out how much lower the risk of the infection became when mandatory gloving was in effect.

  • Joint Commission issues Sentinel Event Alert on medical device alarm safety

    The Joint Commission issued a Sentinel Event Alert on April 8 warning hospitals against alarm fatigue caused by medical devices. According to the alert, thousands of alarm signals occur in each hospital unit, each day, and an estimated 85% – 99% of the signals do not require clinical intervention. What does the Joint Commission recommend hospitals do to combat alarm fatigue and minimize risk to patients? Find out on the Patient Safety Monitor Blog.

  • Researchers identify 12 steps for effectively reducing readmissions

    The 12 steps of the Re-engineered Discharge (RED) toolkit published by the Agency for Healthcare Research and Quality (AHRQ) are effective at reducing readmissions and visits to the emergency department following discharge, according to researchers at Boston University Medical Center. Researchers also updated the set of steps for reducing readmissions, including a new component for overcoming language barriers.

  • Patients in N.Y. sue over syringe reuse

    Fourteen patients have filed a lawsuit against a N.Y. hospital for possible exposure to hepatitis B, hepatitis  The suit also names the hospital’s parent company, Guthrie Healthcare System, along with the nurse who allegedly reused syringes on more than 230 patients.

  • Roadmap for improving patient care laid out in study

    A group of interdisciplinary research teams conducted 40 studies that investigate how nurses contribute to and can improve patient care quality. What exactly did the study identify?

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  • Patient Safety Monitor

    Patient Safety Monitor

    Get cutting-edge best practices and tools to improve your patients’ safety.
    Patient Safety Monitor
    features a fully customizable, Web-based crosswalk that organizes state, CMS, and Joint Commission requirements by topic. It also provides access to news and analysis on dozens of the most challenging patient-safety issues via the monthly journal, the tools and templates library, and the weekly e-newsletter.

    Learn more.